Infections of the central nervous system.

Infections of the central nervous system are common, serious medical conditions. One hundred consecutive adult cases with purulent meningitis of known etiology encountered by the Medical Service at Parkland Memorial Hospital were reviewed. Streptococcus pneumoniae was the most common pathogen (56 cases), followed by Neisseria meningitidis (16 cases) and Listeria monocytogenes (seven cases). Hemophilus influenzae, Staphylococcus aureus, and streptococci each accounted for five cases. An additional 15 patients had purulent meningitis with a pathogen being isolated. Twenty five purulent meningitis cases of known etiology after trauma or neurosurgery were reviewed. Staphylococcus aureus (five cases), Staphylococcus epidermidis (four cases), and gram negative bacilli (14 cases) were the most common pathogens. Review of intracranial suppurative infections demonstrated advances in microbiology, antibiotic therapy, and imaging, leading to improvements in therapy. Subdural empyema continues to be a difficult diagnosis to make and apparently is related to the anatomic pathology of the infectious process. To illustrate salient features about granulomatous meningitis and encephalitis, cases of tuberculous meningitis, herpes simplex encephalitis, St. Louis encephalitis, and encephalitis of undetermined etiology are presented and discussed.     

Update on chronic hepatitis C in hemophiliacs

BACKGROUND AND OBJECTIVES: Hepatitis C virus (HCV) infection is an important cause of morbidity and mortality in patients affected by hereditary bleeding disorders and treated with non-virus inactivated clotting factor concentrates during the 1970s. INFORMATION SOURCES: In this review, we briefly report the present knowledge about HCV infection in hemophilic patients. The natural course of hepatitis C virus infection in hemophiliacs is described, by analyzing the prevalence of HCV infection, the genotype distribution and the risk factors involved in the progression of chronic hepatitis into severe liver disease such as cirrhosis, liver decompensation and hepatocellular carcinoma. STATE OF THE ART AND PERSPECTIVES: We focus on the most important advances in the treatment of hepatitis C in hemophiliacs.     

Leukotrienes in the rat central nervous system.

Leukotrienes C4, D4, and E4 were isolated after incubation of rat brain tissue in vitro with the ionophore A23187 and arachidonic acid. Identification of the compounds was carried out using high-performance liquid chromatography, radioimmunoassay, and bioassay. Average production of leukotrienes C4, D4, and E4 during 10 min of incubation was estimated to 25, 8, and 0.7 pmol per g of brain tissue (wet weight), respectively. Radioimmunoassay determinations indicated in vitro biosynthesis of leukotriene C4 in most regions of the brain, with the highest levels obtained in the hypothalamus and the median eminence. In slices from the caudate nucleus, ionophore A23187 caused a dose-dependent stimulation of leukotriene C4 formation with maximal effect at 5 microM. Leukotriene C4 synthesis of rat brain tissue was inhibited by 30 microM nordihydroguaiaretic acid. Finally, using the indirect immunofluorescence technique, nerve endings in the median eminence and cell bodies in the preoptic area reacting with antibodies raised against leukotriene C4 were observed.     

Central nervous system bleeding in patients with rare bleeding disorders

Summary. Central nervous system (CNS) bleeding is one of the most severe and debilitating manifestations occurring in patients with rare bleeding disorders (RBDs). The aim of this study was to retrospectively collect data on patients affected with RBDs who had CNS bleeding, to establish incidence of recurrence, death rate, neurological sequences, most frequent location, type of bleeding and efficacy of treatments. Results pertained to 36 CNS bleeding episodes in 24 patients with severe deficiency except one with moderate factor VII (FVII) deficiency. Six patients (25%) experienced a recurrence and two had more than one recurrence. Seven patients (29%) had an early onset of CNS bleeding before the first 2 years of life, others (71%) later in life. In 76% of cases, CNS bleeding was spontaneous. CNS bleeding was intracerebral in 19 cases (53%), extracerebral in 10 (28%) and both intracerebral and extracerebral in two cases (6%). Neurosurgery was performed in 11 cases, in association with replacement therapy in seven cases. Seizures were noted in four patients. Residual psychomotor abnormalities were seen in two patients. No death was recorded. To prevent recurrence, 17/24 patients (71%) were put on secondary prophylaxis. In conclusion, recurrence of CNS bleeding was confirmed to be relatively frequent in patients with severe FV, FX, FVII and FXIII deficiencies. Most patients were managed with replacement therapy alone, surgery being reserved for those with worsening neurological conditions. Our results indicate that some RBDs require early prophylactic treatment to prevent CNS bleeding. Optimal dosage and frequency of treatment need further evaluation.     

Laboratory diagnosis of central nervous system infections.

The laboratory diagnosis of CNS infection is essential for optimal therapy. Acute infection requires rapid turn-around testing with high predictive values, that is, the ability of a test to accurately identify those patients who do or do not have disease caused by a specific etiology. The Gram's stain, fungal stains of direct smears, antigen testing for C. neoformans, and culture of bacteria, fungi, mycobacteria, and some viruses are important tests for the diagnosis of acute infection. The laboratory diagnosis of chronic infection necessitates discussion between the clinician and laboratory technician to allow triaging of testing. Antigen tests for bacteria, fungi, and viruses; antibody tests for multiple microorganisms; and PCR testing for bacteria, M. tuberculosis, and many viruses are all important in limited clinical situations. All testing for acute or chronic disease depends on sufficient specimen that is transported to the laboratory in a manner that will not compromise viability or chemical integrity. Sterile containers that maintain moisture content, exclude oxygen for anaerobic requests, and are stored at proper temperatures (22 degrees C room, 4 degrees C refrigeration, or -20 degrees C freezer depending on pathogen and test) are mandatory. Many laboratory issues addressing the diagnosis of CNS infection are changing or evolving. Most important is the recognition that bacterial antigen testing for the diagnosis of acute bacterial meningitis rarely impacts patient management and is not routinely needed, CSF shunt infections differ from usual meningeal infections and require rapid diagnosis, and TB meningitis remains a difficult disease to diagnosis but may be confirmed first by PCR testing of CSF. In addition, Whipple's disease of the CNS can be confirmed using PCR with CSF; CJD has a marker protein, referred to as 14-3-3 antigen, that can be detected in CSF, and the diagnosis of fungal CNS disease requires careful interpretation of direct smears, antigen and antibody testing, and culture. Most difficult to diagnose among the CNS infections are viral meningitis and encephalitis. The appearance of new etiologies, such as West Nile virus, and the common use of PCR for the herpes viruses and enteroviruses represent important advances. Evolving methods for the laboratory diagnosis of CNS infection represent significant improvements over previous testing; however, the array of tests available demands more attention for appropriate selection, is significantly more expensive, and requires new skills for performance and interpretation. The responsibility for proper use of laboratory testing lies both with the clinician and laboratory technician.     

Naloxone-inaccessible sigma receptor in rat central nervous system.

It has been postulated that the psychotomimetic effects of opiates of the benzomorphan series are due to their activity at the sigma receptor. Therefore, the binding of (+/-)-[3H]ethylketocyclazocine ( [3H]EKC), a benzomorphan, to synaptosomal membranes of rat central nervous tissue was studied. Surprisingly, high concentrations of naloxone, a mu, delta, and kappa receptor antagonist, only inhibited about 80% of the specifically bound [3H]EKC in the spinal cord. This suggested that the remaining 20% of the binding sites were not mu, delta, or kappa. The Scatchard plot of the binding of [3H]EKC was nonlinear but became linear in the presence of naloxone (1 microM), suggesting a single class of naloxone-inaccessible receptor sites. This biochemically readily distinguishable receptor type bound the dextrorotatory isomer of EKC stereoselectively. The sigma agonist N-allylnormetazocine [(+)-SKF 10,047] stereoselectively competed with the binding of [3H]EKC to this naloxone-inaccessible binding site. A number of opiates that have psychotomimetic activity also competed for binding to this binding site. This binding site is designated as sigma binding site according to the nomenclature originally suggested by Martin et al. [Martin, W. R., Eades, C. G., Thompson, J. A., Huppler, R. E. & Gilbert, P. E. (1976) J. Pharmacol. Exp. Ther. 197, 517-532]. The drug selectivity and regional distribution of this sigma binding site in the rat central nervous system are different from that of the mu and delta opioid receptors and phencyclidine receptors. The concentration of the sigma binding site is highest in the spinal cord, pons and medulla, and cerebellum.     

Progress in central nervous system lymphomas

Until recently, primary central nervous system lymphoma (PCNSL) was associated with a uniformly dismal prognosis. It is now reasonable to anticipate long‐term survival and possibly cure for a significant proportion of patients diagnosed with PCNSL. Accumulated data generated over the past 10 years has provided evidence that long‐term progression‐free survival (PFS) can reproducibly be attained in a significant fraction of PCNSL patients that receive dose‐intensive chemotherapy consolidation, without whole brain radiotherapy. One consolidative regimen that has reproducibly demonstrated promise is the combination of infusional etoposide plus high‐dose cytarabine (EA), administered in first complete remission after methotrexate, temozolomide and rituximab‐based induction. Given evolving principles of management and the mounting evidence for reproducible improvements in survival rates in prospective clinical series, our goal in this review is to highlight and update principles in diagnosis, staging and management as well as to review data regarding the pathogenesis of central nervous system lymphomas, information that is likely to constitute a basis for the implementation of novel therapies that are requisite for further progress in this unique phenotype of non‐Hodgkin lymphoma.     

Cortistatin--functions in the central nervous system

Cortistatin (CST) is a neuropeptide from the somatostatin (SRIF)/urotensin (UII) family named after its predominantly cortical expression and ability to depress cortical activity, which was discovered a decade ago. In vitro assays show CST is able to bind all five cloned somatostatin receptors and shares many pharmacological and functional properties with SRIF. However, distinct from SRIF, CST has been shown to induce slow-wave sleep, reduce locomotor activity, and activate cation selective currents not responsive to somatostatin. Different lines of evidence also indicate that CST, like SRIF, is involved in learning and memory processes. CST-14 may also function as an endogenous anti-convulsant. In addition to its role in cortical synchronization, CST-14 has emerged as an important mediator of immunity and inflammation. This review will cover some of the basic properties of CST in the brain, and will discuss new data on the role of CST in cortical activity.     

Regeneration in the central nervous system

Unlike neonatal axons, mammalian adult axons of the CNS do not regenerate after injury. This developmental loss of regenerative capacity, is correlated with the onset of myelination. Likewise, myelin, or myelin-associated components such as Nogo-A and myelin-associated glycoprotein (MAG) inhibit regeneration from older but not younger neurons. Identification of the molecular events responsible for this developmental loss of regenerative capacity is central to devise strategies to encourage regeneration in adults after injury. Endogenous levels of the cyclic nucleotides cAMP and cGMP have been suggested to determine the neuronal responsiveness to various axonal guidance factors. Elevating cAMP concentrations block Nogo-A or MAG induced inhibition of neurite outgrowth in older neurons, whereas suppressing cAMP levels in young neurons renders them susceptible to Nogo-A and MAG. Interestingly, elevated cAMP levels abrogated the Nogo-A and MAG mediated activation of RhoA and down regulation of Rac1 in adult neurons. In contrast, elevation of cAMP leads to the inactivation of RhoA and prevents activation of downstream effector proteins, while Rac is activated. We therefore conclude that the endogenous neuronal cAMP levels determine the neuronal responsiveness to myelin-associated neurite growth inhibitors by regulating rho GTPase activities.     

Primary central nervous system lymphoma

Primary central nervous system lymphomas (PCNSL) are aggressive malignancies that arise in distinct anatomical sites, which display unique structural, biological and immunological conditions. So far, despite recent therapeutic advances, these malignancies exhibit one of the worst prognoses among all non-Hodgkin lymphomas (NHL). For a long time, radiotherapy (RT) has been the standard treatment, producing a response rate of 60-65% and a notable neurological improvement in most cases. However, relapse usually occurred within a few months after RT, with a median survival of 14 months and a 5-year survival of approximately 15-24%. Although the introduction of systemic chemotherapy has consistently improved survival, the prognosis of PCNSL is still dismal, with high rates of local relapse and consequent death. Defining the optimum therapeutic management is difficult because of potential selection biases in large retrospective reviews and the limited number of prospective studies. Although studies published on PCNSL are increasing, several therapeutic questions still remain unanswered after a decade of research.     

Neurotensin: immunohistochemical localization in rat central nervous system.

Neurotensin immunofluorescence was examined in the rat central nervous system using a well-characterized antiserum directed against this tridecapeptide. Morphological characteristics of the fluorescence indicate its association with neuronal cell bodies and processes in the brain and with cells of the anterior pituitary. Fluorescence is seen in many brain areas, with notable densities in the substantia gelatinosa zones of the spinal cord and trigeminal nucleus, central amygdaloid nucleus, anterior pituitary, median eminence, and preoptic and basal hypothalamic areas.